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Shock and Awe: a Dynamic Approach to Resuscitation

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Shock and Awe: A dynamic approach to resuscitation Critical Care Symposium October 28, 2017 Anna Perrello, RPA-C, MPAS Brian Kersten, PharmD, BCCCP, BCPS Disclosures • Brian Kersten o Nothing to disclose • Anna Perrello o Nothing to disclose Objectives • Identify and explain the physiology of various shock states including distributive, cardiogenic, obstructive and hypovolemic. • Discuss advantages and limitations to static and dynamic predictors of volume responsiveness. • Recognize techniques related to visualization of basic structures and medium identification during bedside ultrasonography. • Evaluate treatment options for shock states using dynamic measures for fluid resuscitation Shock • A heterogenous syndrome best defined as circulatory failure o Originates from mismatch between oxygen delivery (DO2) and oxygen consumption (VO2) • Often becomes apparent in setting of arterial hypotension Differentiating Shock Systemic Mixed Wedge Cardiac vascular venous pressure output resistance oxygen Hypovolemic - Hemorrhage ↓ ↓ ↑ ↓ - Dehydration Cardiogenic - Myocardial infarction ↑ ↓ ↑ ↓ - Arrhythmia - Cardiomyopathy Obstructive - Pulmonary embolism ↑↔ ↓ ↑ ↓ - Tension pneumothorax - Cardiac tamponade Distributive - Septic shock - Anaphylaxis ↑↔ ↑ ↓ ↑ - Neurogenic - Myxedema coma - Post-cardiopulmonary bypass Goals of Therapy in Shock • Restore effective tissue perfusion and normalize cellular metabolism by ensuring systemic oxygen delivery by 1. Aggressive and appropriate fluid resuscitation 2. Supporting CO and MAP • Above are titrated to individual endpoints and used together to assess adequacy of resuscitation 1. Markers suggesting adequate tissue perfusion 2. Markers suggesting adequate intravascular volume 3. Target MAP Shock and Awe • Military doctrine of rapid dominance Question •Global (macrocirculatory) oxygen delivery (DO2) can be best approximated by which variable? 1. Arterial partial pressure of oxygen (PaO2) 2. Arterial oxygen saturation (SaO2) 3. Hemoglobin 4. Systemic vascular resistance (SVR) 5. Stroke volume (SV) Global Tissue Perfusion • ‘Macrocirculation’ o DO2 = CO x CaO2 o DO2 = (SV x HR) x ([0.0138 x Hgb x SaO2] + [0.0031 x PaO2]) • Increasing hemoglobin and oxygen produce minimal changes in oxygen delivery • Heart rate is generally at maximum compensation, therefore o DO2 = SV x (HR) x ([0.0138 x Hgb x SaO2] + [0.0031 x PaO2]) • Regional tissue perfusion (microcirculation) • Not predicted by DO2 Assessing perfusion Physical Exam Laboratory • Mean arterial pressure • Lactate • Mentation o Cerebral perfusion • pH, pCO2 and HCO3 • Urine output • SCVO or SVO (>0.5ml/kg/hr) 2 2 • Capillary refill • Skin perfusion/mottling • Cold (or warm) extremities • Generalized edema o Pulmonary edema • Intra-abdominal pressure Volume Challenge • Reserved for hemodynamically unstable patients with three advantages 1. Opportunity to quantitate response during infusion 2. Prompt correction of fluid (preload) deficits 3. Minimizing risk of volume overload • Only ~50% of hemodynamically unstable patients are fluid responsive after initial resuscitation o Aggressive and overzealous fluid administration can lead to severe tissue edema and compromised organ function Vincent JL. Crit Care Med 2006; 34:1333-1337 Marik PE. Crit Care Med 2013; 41:1774-1781 Question •Which of the following is best to utilize for quantifying a response to a volume challenge? 1. Central venous pressure (CVP) 2. Mean arterial pressure (MAP) 3. Pulmonary capillary wedge pressure (PCWP) 4. Pulse pressure variation (PPV) 5. Urine output Stroke Volume • Dependent on preload and contractility in shock Frank-Starling Curve Stroke volume Stroke Ventricular preload Volume responsiveness - Static CVP = RAP = RVEDP = RVEDV = RV Preload ≈ PCWP = LVEDP = LVEDV = LV Preload Measure* Premise Limitations Takeaway Central venous CVP surrogate for CVP or ΔCVP does not DO NOT USE pressure (CVP) PCWP & correlate with intravascular PCWP = LVEDP volume or stroke index/cardiac (and thus stroke output volume) Pulmonary capillary PCWP = LVEDP LVEDP can be altered DO NOT USE wedge pressure independently of LVEDV; does (PCWP) not *Other measures: left ventricular end diastolic area (LVEDA), right ventricular end diastolic volume (RVEDV) similar concerns Kumar A. Crit Care Med 2004; 32:691-699. Marik PE. Chest 2008; 134:172-178 Marik PE. Crit Care Med 2013; 41:1774-1781 CVP & PCWP and Cardiac Output Osman D. Crit Care Med 2007; 35:64-68 Dynamic Measurements of Fluid Responsiveness • Dynamic measures are used to exploit the existing relationship between heart and lungs during mechanical ventilation • To evaluate a patient’s location on the Frank- Starling curve, the following dynamic measures can be used: o Stroke Volume Variation (SVV) o Pulse Pressure Variation (PPV) o IVC Diameter Variation (∆DIVC) Effects of Mechanical Ventilation on Intrathoracic Structures +Intrathoracic Pressure -Intrathoracic Pressure Compliant Heart (Fluid Responsive) Non-Compliant Heart (Not Fluid Responsive) Stroke Volume Variation (SVV) • Procedure: o Arterial line is placed, and the change in area under the arterial wave form during respiratory variation is compared • ∆SVV 12-13% correlated with an increase of CO ≥ 15% after volume expansion, was highly predictive of fluid responsiveness1 SVV Sensitivity 0.82 Specificity 0.86 1Marik, PE, et al. Stroke volume variation and fluid responsiveness. A systematic review of the literature. Critical Care Med 2009; 37; 2642-7. “Advanced Monitoring Parameters: SVV, PPV.” Change Region, Maquet Getinge Group, www.maquet.com/uk/services/advanced-monitoring-parameters/svv-ppv/. September 2 2017. Pulse Pressure Variation (PPV) • Procedure: o Arterial line is placed, calculated difference (%) of pulse pressure between inspiration and expiration • ∆PPV 12-13% correlated with an increase of CO ≥ 15% after volume expansion, was highly predictive of fluid responsiveness1 PPV Sensitivity 0.89 Specificity 0.88 1Marik, PE, et al. Stroke volume variation and fluid responsiveness. A systematic review of the literature. Critical Care Med 2009; 37; 2642-7. “Advanced Monitoring Parameters: SVV, PPV.” Change Region, Maquet Getinge Group, www.maquet.com/uk/services/advanced-monitoring-parameters/svv-ppv/. September 2 2017. IVC Variation • Non-invasive measure to assess for fluid responsiveness in mechanically ventilated patients • Procedure: o 2D Echocardiography is used, IVC visualized in subxiphoidal view, measurements made in M-Mode during respiratory cycle at ~3cm from right atrium o Difference calculated as ∆DIVC as a percentage • ∆DIVC 12-18% with subsequent increase of CO ≥ 15% after volume expansion, correlated with fluid responsiveness3,4 o Positive Predictive Value: 93% o Negative Predictive Value: 92% 3Feissel, M. et al. Intensive Care Med (2004) 30: 1834.http://doi-org.gate.lib.buffalo.edu//100.1007/s00134-004-2233-5 4Barbier, C. et al. Intensive Care Med(2004) 30:1740. Http://doi-org.gate.lib.buffalo.edu/10.1007/s00134-004-2259-8 Identification of Structures and Mediums on Ultrasound • White: Hyperechoic, often dense/calcified tissue; pericardium, diaphragm • Black: Anechoic; fluid; blood, pleural fluid • Light/Dark Gray: Hypoechoic, isoechoic; organs or structures, soft tissue, may indicate sluggish blood flow, thrombus • Air: White/gray, STRONG reflector of sound waves, impedes visibility, often a limitation during bedside evaluation Identification of Structures and Mediums on Ultrasound 2 3 1 Transducer placed on left chest, along midaxillary line Identification of Structures and Mediums on Ultrasound RA LA LV Parasternal Long Axis Identification of Structures and Mediums on Ultrasound Transducer placed subxiphoid view IVC Variation ∆DIVC ∆DIVC Inferior Vena Cava Variation to Assess for Fluid Responsiveness Is this patient likely to be fluid responsive? ∆DIVC(%)=[(IVCDb-IVCDa)/IVCDb]x100 ∆DIVC(%)=[(2.30-2.22)/2.22]x100=3.6% Limitations of PP, SV and IVC Variation • Limitations: o Patient must be mechanically ventilated with a Vt of at least 8ml/kg of IBW o No arrhythmias present o Passive ventilation o No increase in IAP or open chest o Requires arterial line placement (PPV and SVV) o Required Hemodynamic Monitoring Device (SVV) o Experience of ultrasonographer (IVC Variation) Passive Leg Raise • Non-invasive measure to assess for fluid responsiveness in spontaneously breathing patients • PLR to 30˚ simulates ~300cc fluid bolus to the patient that is easily reversible • Procedure: o Patient is placed in a supine position, passive leg raise of 30˚, returned to supine position, administered 500cc NS o HR, BP and aortic flow velocity measured at each interval Passive Leg Raise • Aortic Flow Velocity (marker of SV) measured with bedside echocardiography, an increase of CO and SV >12% was noted to be significant and correlated with fluid responsiveness2 Sensitivity Specificity CO 63% 89% SV 69% 89% • Limitations: o Good echocardiographic widows required for evaluation of SV and CO o Advanced echocardiographic skills o Technically difficult in many ICU patients 2Maizel, J. et al. Intensive Care Med (2007) 33: 1133. http://doi.org.gate.lib.buffalo.edu/10.1007/s00134-007-0642-7 Summary of Static and Dynamic Measures Method Technology Sensitivity, Specificity, AUC Pulse pressure Arterial waveform Sensitivity 89% variation (PPV) Specificity 88% Stroke volume Pulse contour analysis Sensitivity 82% variation (SVV) Specificity 86% IVC Variation (∆DIVC) Echocardiography Sensitivity 93% Specificity 92% Passive Leg Raise Echocardiography Sensitivity 63% Specificity 89% Central
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